Transcript Presentation - National Resource Center on Nutrition and

Developing
Service Packages and
Taking Them to Market
W. June Simmons, MSW, CEO
Bringing medicine,
families and
community-based services
together.
Partners – Local, state, national leader
•
Largest HCBS waiver provider in California
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CA State technical assistance center for evidence-based selfmanagement programs for high-risk chronically ill adults
– Chosen by CDA & CDPH
– 100+ partners in the delivery system
– Reach 6,000+ participants/year in 9 counties
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Developer of HomeMeds and Healthy Moves
– ACL/AoA High-level evidence-based prevention & health promotion
programs
– Co-founder & business office for national Evidence-Based Leadership
Council representing 19 EB programs
•
ACL Targeted Technical Assistance – selected site PLUS
planning/steering team
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Research partner for Kaiser Permanente
Health Reform: Moving From
Volume to Value
• Infrastructures and reimbursement are
transforming
• The roles of hospitals, physicians and payers are
blurring and social skills are more recognized
• Major consolidation – unpredictable future
• Growing role for community and agencies
• MEDICAL DOLLARS NEED TO BE REINVESTED IN
HEALTH RESULTS – WE BRING SOLUTIONS
Evidence-Based Health Promotion: What’s Next?
Building Infrastructures for Health
• Medical care systems need to connect to community
resources to build health
• Creation of widespread community-based programs
to address lifestyle change are needed – especially
to manage risks like diabetes progressing, heart
disease and falls
• Pro-active care is emerging – the whole person
• Evidence-based CBO programs are essential
Evidence-Based Health Promotion: What’s Next?
More than new infrastructure
• Need “pathways to health”
– methods to identify those who will benefit
– brief methods to open the door to change
– skills and tools to enhance self management
– Customize interventions to target population
– What’s the DOFR?
Health Care + Social Services =
Better Health, Lower Costs
• Address social determinants of health
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Personal choices in everyday life
Isolation, family structure/issues, caregiver needs
Environment – home safety, neighborhood
Economics – affordability, access
• Social Service Agencies Have Advantages
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Time to probe, trust, different authority
Cultural/linguistic competence
Lower cost staff & infrastructure
High impact evidence-based programs
Why? Low Ratio of Social to Health Service
Expenditures in U.S.
for Organization for Economic Co-operation and Development (OECD) countries, 2005.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
1% spend 21%
5% spend 50%
The Upstream Approach: What
would happen if we were to spend more
addressing social & environmental
causes of poor health?
Concentration of Risk
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Functional Limitation
Dementia
Frailty
Serious illness(es)
Hospital/ ER use
Most of Costliest 5% have
Functional Limitations
http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
Surprise! Home and Community Based
Services are High Value
• Improves quality: Staying home is
concordant with people’s goals.
• Reduces spending: Based on 25 State
reports, costs of Home and Community
Based LTC Services less than 1/3rd the cost
of Nursing Home care.
Because of the Concentration of Risk
and Spending, Home and Community
Care Principles and Practices are Vital
to Improving Quality and Reducing
Cost
This is an Expertise
• Highest risk, highest cost population is
ours: functional limitation, frailty, cognitive
impairment +/- serious illness
• A fully integrated service line that also
helps keeping people out of the top 5%
Targeted Patient Population Management with
Increasing Disease/Disability
Home Palliative Care
Late
Life
Post Acute and Long Term
Supports and Services
Hot Spotters!
Complex Chronic
Illnesses w/ major
impairment
Chronic Condition(s) with
Mild Functional &/or
Cognitive Impairment
Chronic Condition with Mild Symptoms
Well – No Chronic Conditions or Diagnosis
without Symptoms
Evidence Based SelfManagement, Home
Assessment and HomeMeds
HCBS in Active Population Management – Value
Propositions: Who Pays and Who Saves?
EOL
25% of all Medicare is Last Year of Life: Duals Plans;
Medicare Advantage SNP; ACO/MSSP
LTSS &
Caregiver
Support
Care Transitions
HomeMeds/Home
Safety Assessment
EB Self-Management:
CDSMP/DSMP; MOB; Healthy IDEAS;
EnhanceFitness; PEARLS; Fit & Strong
Senior Center – meals, classes,
exercise, socialization
Nursing Home Diversion for Duals Plans
 ED/Hosp: Capitated Providers/Plans
 Readmission penalties: Hospitals
Chronic Disease Management:
Duals Plans; MA SNP
Prevention: MA Plans;
Capitated Med Groups
Overlapping Networks & Service Lines
Evidence-Based SelfManagement Network
• National Network - EBLC
• Statewide TA
Collaborative
• L.A. AAA/Senior Center
Providers
LTSS Network
•Nonprofit Waiver
Contract Holders for Care
Coordination
•Vendor Network
•Respite care
•Meals
•Assisted Transportation
•Home Modifications
•Home alert & monitoring
•DME
Care Transitions/SNF
Diversion Network
3 Service lines to be offered
Evidence-based
Self-Management
Short-term InHome Services
Long-term
Services &
Supports
Independent w/
chronic condition
At risk for
deterioration &
high utilization
Frail/disabled
Care transition
coaching
Service coordination,
HomeMeds,
Stanford Chronic
Disease SelfManagement
(Diabetes, Pain,
Spanish versions)
Risk screening
Psychosocial evaluation
Service coordination
Purchase of services
(meals, respite,
transport, chores)
Some Evidence-Based Programs
SELF-MANAGEMENT
• Chronic Disease Self-Management
• Tomando Control de su Salud
• Chronic Pain Self-Management
• Diabetes Self-Management Program
PHYSICAL ACTIVITY
• Enhanced Fitness & Enhanced
Wellness
• Healthy Moves
• Fit & Strong
• Arthritis Foundation Exercise
Program
• Arthritis Foundation Walk With Ease
Program
• Active Start
• Active Living Every Day
MEDICATION MANAGEMENT
• HomeMeds
FALL RISK REDUCTION
• Stepping On
• Tai Chi Moving for Better Balance
• Matter of Balance
DEPRESSION MANAGEMENT
• Healthy Ideas
• PEARLS
CAREGIVER PROGRAMS
• Powerful Tools for Caregivers
• Savvy Caregiver
NUTRITION
• Healthy Eating
DRUG AND ALCOHOL
• Prevention & Management of
Alcohol Problems
HomeMeds℠ - Opens doors between
CBOs and Healthcare
• HomeMeds℠ is designed to enable community agencies to
keep people at home, out of hospital & nursing home, by
addressing medication safety
• Practice change with workforces that already go to the home
– more cost effective use of existing effort
• Targets problems for significance, accessibility to in-home
staff, and likelihood of positive prescriber response.
• Focuses on adverse effects (falls, confusion, dizziness, vitals)
… then determines if medications may be part of the cause.
• Cost-effective use of geriatric pharmacist for complex
problems
HomeMedsSM Improves Med Safety
• Home visit by nurse or social worker
– Collect comprehensive medication information
– Assess for possible adverse effects & discrepancies
– Screen through software to find potential problems
• Pharmacist review & resolve problems, educate
• Original Model: Find a home visit—add
HomeMeds
• Emerging Models
– Targeted home visits for high-risk patients
– Add to care transitions, CDSMP, caregiver support, etc.
– Part of comprehensive fall prevention initiative
Medication Risk Assessment - HomeMedsSM
• Review of all Meds currently being taken (OTC,
borrowed, in drawers, fridge, etc.)
– Interview about adherence, understanding, side
effects, etc. for each med.
• Signs/symptoms of adverse effects (falls,
confusion, dizziness, BP, pulse)
• Supplementary information about alcohol use,
diagnoses, allergies, adherence, etc.
Why should non-healthcare agencies work
on medication safety?
• To thrive, CBOs need to play a new role connecting
the home with the healthcare system
– Meds are major factor in readmissions (72%)
– Home provides unique perspective otherwise unavailable to
healthcare providers.
– Quality measures for health plans and providers relate to
issues such as medication use and fall prevention – HEDIS,
Medicare Advantage Star Ratings
– New focus on population health – identifying and proactively
addressing health for high-risk patients
Why Focus on Integrated Networks for
Medical Care and Social Services?
• Improve health care for adults with chronic
conditions through comprehensive, coordinated,
and continuous expert and evidence-based
services
• Add supportive social services to medical care
– Reduce the cost of medical care
– Improve health outcomes
• ACA and Duals plans provide opportunity for
shared cost savings for LTSS
Psychosocial and Environmental
Assessment
• Functional assessment (ADL/IADL)
• Fall Risk – Medications, lighting, trip hazards
• Screening for Depression (PHQ 2/9) and Cognitive
Impairment (Mini Mental Status)
• Home safety/cleanliness/maintenance
• Identification of barriers to compliance with treatment
plan
• Evidence of problems (e.g., alcohol bottles, odors,
moldy food)
• Social Support & Services – Both patient and
formal/informal caregivers; Abuse Indicators
Special Requirements to Meet
• Metrics – Demonstrating Results
– Impacting health outcomes/service use
• Medical Loss Ratio
– Accreditation or Licensure
– Licensed Supervision
• How are Payers Judged and Paid?
– Quality and Patient Satisfaction/Retention
Examples of Positive Outcomes
• Compared to patients who met referral criteria but did not receive the
home visit (valuing readmission at $15,000 and ED visit at $5,000)
– 12.8% lower rate of ED use
– 22% lower rate of readmissions
– ROI 53% - $135,000 cost avoidance on $88,000 investment
• Compared to the hospital’s readmission rate for the medical group
– 40% lower rate of readmissions
– ROI 155% - $224,000 cost avoidance on $88,000 investment
• Medication Issues Identified and Recommendations Made by
PharmD: 63%
• Other issues identified (e.g., PHQ-9, caregiver or financial need):
54%
HEDIS/5 Star Measures
• Additional benefits of HomeMeds Plus are to
HEDIS measures.
• In particular those around:
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Care Coordination
Medication Compliance
Risk Assessment
Care for Older Adults
Fall Risk Assessment
Facing the future
together
Networks of CBOs will enable all
boats to rise together and give us
scale to compete successfully in
post-ACA markets
Getting Started on an Exciting Journey!
For more information
Contact:
June Simmons, CEO
Partners in Care Foundation
818-837-3775
[email protected]
www.picf.org